Corporate Compliance

HealthDataInsights posts new issues for medical necessity claims

Compliance Monitor, November 30, 2011

HealthDataInsights (HDI) added five new issues for medical necessity claims to its CMS-approved list for providers in all Region D states. HealthDataInsight was awarded Region D, which consists of 17 states and three territories including: Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas. Further information is available on the HDI website.

The HDI website describes the following new issues:

  • Circulatory system disorders except upper limb and toe with MCC (DRG 239). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Revision of hip or knee replacement with MCC (DRG 466). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Ventricular shunt procedures without CC/MCC (DRG 033). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Ventricular shunt procedures with MCC (DRG 031). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.
  • Ventricular shunt procedures with CC (DRG 032). Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary.

This article is adapted from a post on the Revenue Cycle Institute website.
 

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